Gondracenter - Family HIPAA Form

HIPAA Authorization Form for Providers/Family Members/Friends
I, First Name Last Name , give permission for Gondra Center for Reproductive Care & Advanced Gynecology to disclose and release my protected health information described below to:
Health Information to be disclosed (check all that apply):

My complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions) ORMy complete health record, as above, with exceptions
With the exception of the following information: (check as appropriate)

Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther
This health information may be used to enable the persons I authorize to know and understand my condition and my treatment or treatment options, for treatment or consultation, for claims payment purposes, or related reasons.
This authorization shall be effective until (Check one):

All past, present, and future periodsOr unless I revoke it. (NOTE:You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)
Date

MonthDayYear
Date
Event
Name of the Individual Giving this Authorization
Signature of the Individual Giving this Authorization

Clear
Date

MonthDayYear
Date
Should be Empty:

HIPAA Authorization Form for Providers/Family Members/Friends